Sharps Injuries - Prevention in the NSW Public Health System

Policy Directive Department of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/ Sharps Injuries - Prevention in the NSW Public Health System Document Number PD2007_052 Publication date 29-Jun-2007 Functional Sub group Clinical/ Patient Services - Infectious diseases Clinical/ Patient Services - Incident management Population Health - Infection Control Personnel/Workforce - Occupational Health & Safety Personnel/Workforce - Learning and Development space space space Summary The purpose of this policy directive and associated guidelines is to prevent or minimise sharps injuries in the NSW public health system by directing organisations to develop a sharps injury prevention program utilising a risk management framework. The document also provides guidance for organisations to meet OHS legal obligations with regards to sharps injuries Author Branch Aids and Infectious Diseases Branch contact Mark Friedewald 4320 2132 Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Affiliated Health Organisations - Non Declared, Affiliated Health Organisations - Declared, Public Health System Support Division, Community Health Centres, Dental Schools and Clinics, Divisions of General Practice, Government Medical Officers, NSW Ambulance Service, Public Hospitals Audience All Staff Distributed to Public Health System, Community Health Centres, Dental Schools and Clinics, Divisions of General Practice, Government Medical Officers, Health Associations Unions, Health Professional Associations and Related Organisations, NSW Ambulance Service, NSW Department of Health, Public Hospitals, Private Hospitals and Day Procedure Centres, Private Nursing Homes, Tertiary Education Institutes Review date 29-Jun-2012 File No. Status Active Director-General space This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for NSW Health and is a condition of subsidy for public health organisations.

Policy Directive POLICY and GUIDELINES for the PREVENTION of SHARPS INJURIES in the NSW PUBLIC HEALTH SYSTEM May 2007

Table of Contents Page 1.0 About This Document 1.1 Prevention of sharps injuries 4 1.2 Responsibility 4 1.3 Version 4 1.4 Review 4 1.5 Related NSW Health policies 4 1.6 Related NSW legislation 4 1.7 Additional references and resources 5 1.8 Key definitions 6 1.9 Glossary of acronyms 8 2.0 Introduction 2.1 Background 9 2.2 Environmental scan 9 2.3 Purpose of the policy directive and guidelines 10 2.4 Application of the policy directive and guidelines 11 2.5 NSW Health policy statement 11 2.5.1 Clinical indicator data relating to sharps injuries 12 2.5.2 Safety-engineered sharps devices 13 2.5.3 Sharps disposal containers 13 2.5.4 Product evaluation committees 14 2.5.5 Education and training 15 2.5.6 Clinical practice review and redesign 16 2.5.7 Governance 16 3.0 Risk Management Process 3.1 Introduction 17 2

3.2 Hazard identification 17 3.3 Risk assessment 17 3.4 Risk elimination and control strategies 18 3.4.1 Hierarchy of risk controls 18 3.4.2 Post exposure management 18 4.0 Documentation Relating to Sharps Injury Prevention Programs 4.1 Performance indicators 20 4.2 Operational aspects 20 4.3 Evaluation and review 20 5.0 Guidelines for a Sharps Injury Prevention Program 5.1 Key elements of a sharps injury prevention program (flow chart) 22 6.0 Sample Tools for Use in Developing a Sharps Injury Prevention Program Tool A. Survey of healthcare workers on exposures to blood sharps injuries (sample) 23 Tool B. List of safety-engineered sharps device categories 27 Tool C. Worksheet for estimating implementation costs of safety-engineered medical devices (sample) 30 Tool D. Safety-engineered sharps device pre-selection worksheet (sample) 32 Tool E. Safety-engineered sharps device evaluation form (sample) 36 Tool F. Clinical assessment sheet for intravenous cannulation (sample) 40 Tool G. Clinical assessment sheet for blood collections (sample) 42 Tool H. Performance criteria for users of safety-engineered sharps devices 44 Tool I. Suggested inclusions for exposure management packs 45 Tool J. Tool K. Baseline sharps injury prevention program assessment worksheet (sample) 46 Survey of healthcare workers perceptions of organisational safety culture (sample) 53 3

1.0 About This Document 1.1 Prevention of sharps injuries This document provides the policy and guidelines for preventing sharps injuries in the NSW public health system. Copies may be obtained at: http://www.health.nsw.gov.au/policies/index/html 1.2 Responsibility AIDS and Infectious Diseases Branch 1.3 Version Final version - May 2007 1.4 Review This policy directive will be subject to regular review, consistent with PD2005_481: Policy, Guideline and Information Bulletin Distribution System for the NSW Department of Health. 1.5 Related NSW Health policies PD2005_409: Workplace Health and Safety: Policy and Better Practice Guide PD2007_036: Infection Control Policy PD2005_414: Infection Control Program Quality Monitoring PD2005_354: WorkCover NSW Reporting Requirements: Occupational Exposures to Blood-Borne Pathogens PD2005_311: HIV, Hepatitis B and Hepatitis C - Management of Health Care Workers Potentially Exposed PD2007_006: Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases PD2005_162: HIV, Hepatitis B or Hepatitis C Health Care Workers Infected PD2005_187: Orientation Policy for NSW Health PD2005_189: Occupational Health, Safety and Rehabilitation Numerical Profile PD2005_132 Waste Management Guidelines for Health Care Facilities NSW Health Purchasing and Supply Manual for Public Health Organisations http://www.health.nsw.gov.au/audit/manuals/purch_supply.pdf 1.6 Related NSW legislation Occupational Health and Safety Act 2000 Occupational Health and Safety Regulation 2001 4

Medical Practice Regulation 2003 Nurses and Midwives Regulation 2003 Dentists Practice Regulation 2004 Dental Technicians Registration Regulation 2003 Physiotherapists Regulation 2002 Podiatrists Regulation 2005 1.7 Additional references and resources Department of Health 73 Miller Street North Sydney NSW 2059 Ph (02) 9391 9305 http://www.internal.health.nsw.gov.au/ Needlestick Injury Hotline: 1800 804 823 WorkCover NSW Locked Bag 2906 Lisarow NSW 2252 Ph (02) 4321 5000 http://www.workcover.nsw.gov.au/ Code of Practice - Notification Requirements for Occupational Exposure to Human Blood-Borne Pathogens http://www.workcover.nsw.gov.au/nr/rdonlyres/4ce35153-9c01-420e-a055-726ccf4a5c14/0/blood_pathogens_4430.pdf National Code of Practice for the Control of Work-related Exposure to Hepatitis and HIV (Blood-borne) Viruses, [NOHSC:2010 (2003)], NOHSC, 2 nd edition, December 2003. http://www.ascc.gov.au/nr/rdonlyres/14850412-bf2d-4e22-b4f7-076cbd4383f6/0/hiv_2ed_2003.pdf Guidelines for Clinical Products Health Procurement (2005) http://internal.health.nsw.gov.au/business/hp/maindocs/library.htm NSW Health web address with links to: data on blood-borne virus notifications; and Infection Control http://www.health.nsw.gov.au/ AS/NZS 4360:2004 Risk Management http://www.riskmanagement.com.au/ Sharps Injury Prevention Workbook Centers for Disease Control and Prevention. Atlanta: Georgia http://www.cdc.gov/sharpssafety/pdf/workbookcomplete.pdf Sharps Safety and Needlestick Prevention, 2nd ed. 2003 ECRI http://www.ecri.org/ 1.8 Key definitions used throughout this document Clinicians Healthcare workers who provide direct clinical care to patients / clients. 5

Clinical assessment A framework used to assess a clinician s practice including their adherence to a defined set of principles for specific clinical skills or procedures to ensure standardised practices in the delivery of patient care. Hazard A source or situation with a potential for harm in terms of human injury or ill health, damage to property, damage to the environment, or a combination of these. Healthcare workers Persons involved in the delivery of health care services in, or on behalf of the NSW public health system and who have contact with patients / clients or with blood or body substances. Visiting Medical Officers, students, trainees, mortuary attendants, and hospital support staff such as cleaners and launderers are included under this definition. Hollow bore needles These are needles, of varying gauges, designed to enable fluids (bodily or other) to pass through them to or from a collection vessel e.g. a syringe. Induction program A program conducted for new staff specifically related to the work area or department in which they will work. NSW Health Service Consists of staff employed in all Area Health Services, all statutory health corporations, any declared affiliated health organisations, the Ambulance Service of NSW and the Public Health System Support Division (currently includes the Institute of Medical Education and Training, Health Technology and HealthSupport). NSW public health system Consists of all Area Health Services, all statutory health corporations, all affiliated health organisations in respect of their recognised services, the Ambulance Service of NSW and the Public Health System Support Division (currently includes the Institute of Medical Education and Training, Health Technology and HealthSupport). Organisation For the purpose of this policy directive, this term refers to any entity that is part of the NSW public health system. 1.8 Key definitions (cont.) Orientation program A program whereby new staff are welcomed to an organisation during which the goals and direction for NSW Health and the organisation are articulated. 6

Patient / clients For the purpose of this policy directive, refers to any person receiving health care on health service property, in the home or in the community. Phlebotomy Procedures undertaken for the purpose of vascular access. Such access is predominantly venous in type. Point of use (sharps disposal containers) The placement of sharps disposal containers as close as is practical to the site where sharp devices are used so as to limit the distance between their use and their disposal. Post exposure management Assessment and treatment of healthcare workers who have sustained a potentially contaminated sharps injury. Risk The likelihood and consequence of a potential injury or harm occurring. Risk assessment The overall process of estimating the magnitude of a risk arising from a hazard, before deciding what actions will be taken. Risk control The phase of risk management that involves implementing policies, standards, procedures and physical changes to eliminate or minimise risks. Safety-engineered sharps devices Devices used in the delivery of patient care that have engineering features designed to prevent the device from causing a fluid splash or a sharps injury to those involved in their use or disposal. Safety-engineered sharps devices (active design) The safety mechanisms of these devices require activation after use by the user in order to render them safe. Safety-engineered sharps devices (integrated safety design) Devices with this type of design have a safety feature that is built in as an integral part of the device and cannot be removed. Safety-engineered sharps devices (passive design) The safety mechanism of these devices is integrated and remains in effect before, during and after use. Their activation is not dependent on any action by the user and cannot be bypassed or forgotten. 1.8 Key definitions (cont.) Sharp Object or device capable of inflicting a penetrating injury and includes needles, scalpel blades, wires, trocars, auto lancets, stitch cutters and broken glassware. 7

Sharps injury Any injury that results in piercing of the skin by a needle or other sharp object or device. For the purpose of this policy directive a sharps injury (either clean or contaminated) is one that occurs as a result of a work related activity. 1.9 Glossary of acronyms Sharps injury prevention program A systematic approach that operates within an OHS framework and is aimed at eliminating or minimising sharps injuries to healthcare workers. BBV HBV [blood borne virus] [hepatitis B virus] HCV HCW HIV IIMS IM IV NSI OHS PD PEC PEP PI PPE SC SESD [hepatitis C virus] [healthcare worker] [human immunodeficiency virus] [Incident Information Management System] [intramuscular] [intravenous] [needle stick injury] [occupational health and safety] [policy directive] [product evaluation committee] [post exposure prophylaxis] [performance indicator] [personal protective equipment] [subcutaneous] [safety-engineered sharps device] 8

2.0 Introduction 2.1 Background The General Purpose Standing Committee No.1 inquiry into Serious injury and death in the workplace was convened in 2004. Recommendation 13 of the report that resulted from the inquiry directed NSW Health, in conjunction with WorkCover NSW to undertake further study of the costs and benefits of introducing retractable needles to the NSW health system. Government response to the report proposed further study of a range of sharps safety devices in addition to retractable needles. NSW Health established the Sharps Safety Project in April 2005 in response to Recommendation 13. The action plan for this project was structured in accordance with the occupational health and safety (OHS) framework prescribed in PD2005_409 Workplace Health and Safety: Policy and Better Practice Guide - NSW Health. A comprehensive approach to reducing sharps injuries in the NSW public health system was undertaken that included an exploration of a range of risk reduction strategies. 2.2 Environmental scan The Occupational Health and Safety (OHS) Regulation 2001 directs employers to eliminate or control any foreseeable workplace risk. Most sharps injuries are a foreseeable workplace risk and are identified internationally as being a significant problem for healthcare workers (HCWs), particularly needle stick injuries (NSIs). The most considerable risk from NSIs is transmission of blood-borne viruses (BBVs) such as hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV). This risk is dependent on the prevalence of the viruses in the general population; the transmission rate (higher with HBV and HCV than HIV); and vaccination coverage for HBV. Estimations of seroconversion rates following NSI are: 1.6% - 40% for HBV, depending on e antigen presence and DNA status; 1.8% - 10% for HCV, depending on PCR status; and 0.3% for HIV. The highest rates of sharps injuries identified in the international literature are associated with the use of hollow bore needles attached to disposable syringes. The activities associated with the greatest risks of sharps injuries are in the administration of routine intramuscular (IM) and subcutaneous (SC) injections followed by phlebotomy procedures. In excess of eighty percent (80%) of all reported sharps injuries involve a contaminated needle. The use of sharps in organisations that provide health care is ubiquitous due to increased levels of patient acuity, the type of medical interventions undertaken, vaccination programs and patients with increasingly complex illnesses. In addition, seroprevalence of BBVs is significant within the general community of NSW and it is probable that those who are considered infectious will require inpatient or outpatient health 9

care at some stage during their lives. Peer reviewed literature cites a high level of under-reporting (ranging from 30-80%) associated with sharps injuries incurred by HCWs. Factors identified as being associated with underreporting include: HCWs assessing themselves as having a low risk of disease transmission from their injury; the complexity of injury reporting; or the time lost from the workplace as part of injury reporting and associated management. In 2005, enhanced data collection was introduced to the NSW public health system (Area Health Services only) via the Infection Control Quality Monitoring Program to assist NSW Health in better understanding the causes and circumstances of sharps injuries. The data will enable more appropriate quality improvement programs and policy initiatives to be developed. Data reported from NSW public hospitals since commencement of this program indicate that sharps injuries pose a significant risk to HCWs in NSW. Preliminary results indicate that forty percent (40%) of HCWs who experience a sharps injury in NSW are registered nurses with medical officers also highly represented, and that more sharps injuries involve hollow bore needles than any other sharp. These figures are consistent with those that have been reported by the International Health Care Worker Safety Center at the University of Virginia Health System. (http://www.healthsystem.virginia.edu/internet/epinet). The prevention of sharps injuries is an important step in preventing the transmission of BBVs to HCWs. While risks to individual healthcare workers may be viewed as relatively low, the risk for the healthcare worker population is of concern. The costs associated with sharps injuries are potentially substantial. These costs can be categorised as: emotional (affecting the HCW and their families); physical (including investigative processes and injuries to workers); and financial, associated with both prevention (especially the introduction of safety-engineered technology) and management of injuries. While a number of generic issues associated with sharps safety are relevant to all organisations, certain clinical specialties have distinct concerns that would best be addressed in a specific risk management program. 2.3 Purpose of the policy directive and guidelines The purpose of this policy directive and associated guidelines is to prevent or minimise sharps injuries in the NSW public health system. The associated objectives are to: ensure that organisations develop a sharps injury prevention program that protects staff, patients and members of the community; 10

provide a risk management framework for the development of a sharps injury prevention program; provide guidance for meeting OHS legal obligations with regards to sharps injuries; reduce adverse outcomes of sharps injuries such as BBV transmission if, and when such injuries do occur; and ensure that the personal and organisational costs associated with sharps injuries are minimised. In this document the use of the word: Must indicates a mandatory practice required by law and/or by NSW Health policy directive; and the word Should indicates a strongly recommended action or practice that is to be followed unless there are sound reasons for taking a different course of action 2.4 Application of the policy directive and guidelines This document contains the policy and guidelines for the NSW Health Service on prevention of sharps injuries. In addition, as the Determination of Conditions of Subsidy requires (to the extent permitted by law) non declared affiliated health organisations to comply with policy directives dealing with the terms and conditions of employment of staff employed in the NSW Health Service and to provide to staff the same conditions of employment as those set out in industrial instruments applicable to staff employed in the NSW Health Service, the policy is to be applied across the NSW public health system. The policy also applies to all HCWs providing services on behalf of the NSW public health system (see definitions page 6). Licensed private health care facilities in NSW should have regard to this policy directive and guidelines as a reference for the development of sharps injury prevention programs. 2.5 NSW Health policy statement This document is to be read in conjunction with NSW Health policy directives: PD2007_036 (Infection Control Policy); PD2005_311 (HIV, Hepatitis B and Hepatitis C - Management of Health Care Workers Potentially Exposed); PD2005_354 (WorkCover NSW Reporting Requirements: Occupational Exposures to Blood-Borne Pathogens); PD2005_409 (Workplace Health and Safety: Policy and Better Practice Guide); and PD2005_414 (Infection Control Program Quality Monitoring). Staff in the NSW public health system have the right to work without concern of experiencing a sharps injury. For this right to be realised, the mutual obligation of employers and staff to ensuring a culture of safety must be acknowledged, enhanced and promoted. To effectively meet obligations arising out of the OHS Act 2000 and the OHS Regulation 2001 organisations must address the hazard of sharps injuries. Therefore, organisations within the NSW public health system must implement a sharps injury prevention program. The OHS risk management process must be 11

used in the development of a sharps injury prevention program as per the OHS Regulation 2001 (refer to section 3. of this document). The process for developing a sharps injury prevention program should therefore include: identification and documentation of relevant performance indicators (PIs); undertaking baseline measurements prior to commencement of the program; planning and implementation of the program; monitoring of risk control measures; measurement of PIs over time; documentation at all stages of the process; and evaluation of the program and identification of opportunities for continuous improvement. An effective sharps injury prevention program must include (refer also to section 5. of this document): timely, appropriate consultation with HCWs and their representatives; identification of foreseeable workplace hazards associated with the use of sharps; the risk assessment of sharp devices used in clinical areas; the risk assessment of sharp devices used in other work areas e.g. community settings, laundries, waste collection services; the implementation of appropriate control strategies; appropriate supervision of staff; and appropriate education and training programs for staff. An effective sharps injury prevention program should also incorporate: the collection and analysis of clinical indicator data relating to sharps injuries (to assist with hazard identification and risk assessment, and to evaluate the effectiveness of risk elimination and control strategies); the identification of situations where it may be practicable and clinically appropriate to introduce safety-engineered sharps devices (SESDs); clinical practice review and redesign strategies; and the formation of and appropriate representation on product evaluation committees. 2.5.1 Clinical indicator data relating to sharps injuries Clinical indicator data relating to sharps injuries must be collected and reported in accordance with PD2005_414 (Infection Control Program Quality Monitoring). These data should be reviewed regularly at a local organisational level in combination with other relevant data such as those generated by the use of audit tools and risk assessments to provide a comprehensive sharps safety profile. Sharps injury trends, incidence, ongoing risks and compliance with injury reporting that is less than optimal should be communicated to appropriate departments and advisory committees within the organisational structure. These include, for example, Infection 12

Control, OHS and Product Evaluation Committees. Clinical indicator data relating to sharps injuries should be used to inform policy development; improve or modify clinical practice; establish educational interventions; and inform device purchasing decisions. (SEE TOOL A) 2.5.2 Safety-engineered sharps devices As SESDs have the potential to contribute to the reduction or elimination of sharps injuries, organisations should consider their use where practicable and clinically appropriate. Clinical indicator data relating to sharps injuries, audits and risk assessments should be utilised to ensure that SESDs are only considered for the purpose of improving safety at the point where the risk is greatest or where actual injuries have occurred i.e. before use, during use, directly after use, upon disposal or after disposal. It is advised that prior to the introduction of SESDs into a particular area, devices under consideration must be trialed in that area under usual clinical circumstances. Results must be evaluated in consultation with users of the device. Where the use of SESDs is determined by risk assessment to be clinically appropriate a replacement strategy for the existing conventional sharps devices should be undertaken. (SEE TOOL B ) Where SESDs have been purchased for implementation organisations should within 3 years of this policy directive being released: develop a coordinated purchasing and usage strategy that includes the specific device categories used within the organisation; and ensure available devices are implemented in clinical areas prioritised on basis of risk. 2.5.3 Sharps disposal containers All SESDs that have been implemented should be re-evaluated at least annually to: evaluate whether they have contributed to a reduced incidence of sharps injuries; determine the need for additional training; identify adverse affects on patient outcomes; identify adverse affects on HCW safety; and review contemporary technology trends Sharps disposal containers must be placed (temporarily or permanently) as close as practical to the point of use of sharp devices to limit the distance between their use and disposal. If it is determined that (point of use) sharps containers are unable to be made available for specific procedures or settings, rigid containers that are puncture resistant may be used to transport sharps for appropriate disposal 13

The type of sharps disposal containers in use by organisations must be able to accommodate the variation in sizes and quantities of sharps used at a particular location / point of use. In particular, the type of sharps disposal containers used on resuscitation and emergency equipment trolleys should be standardised within each organisation to ensure that they can accommodate all medication ampoules and sharps used in emergency situations. Optimal height requirements for mounting sharps disposal containers should be determined by risk assessment taking into account the type used and the manufacturer s recommendations, the range of heights and reach of HCWs and the nature of the procedure and location (e.g. community setting, ward, trolley). Once determined, these heights should be incorporated in relevant clinical practice policy documents and documentation pertinent to clinical redesign for new buildings and redevelopments. Standardised methods should be developed for securing and carrying sharps disposal containers during transportation by community based HCWs. PD2007_036 (Infection Control Policy) and the various HCW registration regulations prescribe the minimum requirements for the safe handling of sharps. Each HCW is responsible for the management and disposal of the sharps that they use. 2.5.4 Product Evaluation Committees A Product Evaluation Committee (PEC) is convened for the purpose of review, evaluation, selection and implementation of medical devices for use within organisations. Such committees may be known by other titles and may be either permanent or short-term entities. PECs convened to make procurement decisions regarding sharps devices should ensure: representation for the duration of the selection process by HCWs responsible for direct patient care in those clinical settings where devices under review are being considered for use; representation by or consultation with a designated educator from within the health organisation to provide input about educational requirements associated with any implementation process; evaluation of the device from the perspectives of HCW safety, impact on patient care (quality and safety) and cost effectiveness; (SEE TOOLS C & D) and the use of a standardised evaluation form throughout the selection process. (SEE TOOL E) 14

2.5.5 Education and training An organisational learning model is recommended where education contributes primarily to the professional development of staff and subsequently to organisational outcomes in terms of practice standards and cultural norms. This approach requires education to function via a partnership model in which relevant and appropriate (including mandatory) education is made accessible to HCWs. Accordingly, education will be conducted at frequent intervals to allow all relevant HCWs the opportunity to attend and managers will release HCWs from clinical duties to facilitate their attendance and participation. To achieve the minimum standard of health and safety for workers, employers must ensure that all new staff members are provided with training and / or skills in accordance with PD2005_187 (Orientation Policy for NSW Health). In relation to sharps injury prevention the following elements should be provided: overview of the organisation s sharps injury prevention program; standard precautions; safe handling and disposal of sharps; routine use of sharps disposal containers; reporting of sharps injuries and other blood and body fluid exposures; reporting of identified risks associated with sharps use and disposal; hierarchy of risk controls; the range of SESDs used throughout an organisation and how the specific safety feature/s operate; risks for acquisition of blood borne viruses; occupational vaccination and screening; and post exposure management processes. This training should also include: data relevant to the incidence of sharps injuries within the organisation and the NSW public health system. In regards to contractors and agency staff, organisations should require such staff to have a basic knowledge about the risks associated with sharps injuries and appropriate prevention strategies prior to service engagement. However, mechanisms should be in place where reasonably practicable, to ensure contractors and agency staff receive relevant education and information about work practices and sharps devices specific to the area to which they are deployed. Clinicians who are relocating to a different work area within the organisation, either temporarily or permanently, must be provided with education or training in the use of sharps devices specific to that area with which they are unfamiliar. An annual program of education incorporating sharps injury prevention (elements as per bullet points above) should be provided by each organisation to all staff exposed to the risk of 15

sharps injury, including domestic workers such as cleaners, laundry and food service staff. This information can be integrated into existing, associated educational programs. Education and training should also be implemented in response to specific incidents. Active participation of HCWs can be optimised through the use of a variety of educational techniques. For example, train-thetrainer programs that incorporate the skills and accessibility of front-line staff working in clinical settings should be utilised. Education and training should be provided in a manner appropriate to the workplace and take into account any HCW disabilities, language barriers and varying levels of literacy. De-identified local, aggregate clinical indicator data relating to sharps injuries should be made available to staff on a periodic basis (e.g. annually) to raise awareness of exposure trends. Provision should be made for all staff that perform IV cannulation or phlebotomy procedures to undertake a clinical assessment process. (SEE TOOLS F & G) Organisations may choose to take into account prior training and clinical assessment of staff when determining competence in relation to the procedures of phlebotomy and IV cannulation. 2.5.6 Clinical practice review and redesign Education and training must be provided when new devices are introduced or clinical practices are changed. A clinical assessment process for all relevant clinicians should be considered following the implementation of new SESDs. (SEE TOOL H) There are numerous clinical practices which involve the use of sharps. The process of risk assessment should identify those clinical practices and clinical settings that present a risk. For example, individual assessment of a patient prior to the placement of an intravenous device to determine whether the use of a topical, local anaesthetic may reduce the risk of patient movement. Specific risk elimination and minimisation strategies should be developed and prioritised for action. Consideration should also be given to: the establishment of specific teams of skilled staff to perform phlebotomy procedures; and the establishment of specific IV cannulation teams. If a risk of violence or resistance exists or the patient is a small child, assistance should be sought by the attending clinician during any procedure involving injection or venepuncture and restraint considered. 2.5.7 Governance The Chief Executive (or equivalent) must nominate an individual or department to be responsible for the implementation of a sharps injury prevention program within their organisation. 16

3.0 Risk Management Process 3.1 Introduction Organisations have a legal responsibility in accordance with the OHS Regulation 2001 to eliminate the risk of sharps injury, or if that is not reasonably practicable, to control the risk of sharps injury. General risk management must include: a systematic application of organisational resources to the tasks of identifying, analysing, assessing, controlling and monitoring exposures to risk and adverse affects of those risks; and consultation with relevant staff during all stages of the process. 3.2 Hazard identification Hazard identification is the first step in a risk management framework. Implementation of a standardised process for recognising and defining any hazards relevant to sharps is essential. This should include: reviewing hazard reports and complaints; reviewing incident reports from IIMS (Incident Information Management System); reviewing clinical indicator data relating to sharps injuries to identify high risk areas, clinical settings, procedures and staff groups; inspecting areas with a high incidence of sharps injuries; reviewing procedures where there is a risk of sharps injury; and reviewing manufacturer s information on specific devices. Responsibility for hazard identification in relation to sharps should be delegated to and actively undertaken by the most appropriate department(s) and / or individuals within an organisation. HCWs should also be encouraged to identify and report any hazards associated with sharps. 3.3 Risk assessment The risk assessment process assists in: evaluating the contribution of risk factors; estimating the likelihood and magnitude of the risk arising from an identified hazard; and deciding what actions will need to be taken. Risk assessment is integral to determining the strategies required to achieve the elimination or control of risks. A risk assessment must be performed for every identified hazardous procedure where a sharp(s) device is used for that procedure. In assessing risks associated with sharps, the demographic characteristics of the healthcare workforce need to be considered. These include: clinical areas; training requirements; workforce experience; and clinical environment (including patient characteristics). 17

Specialist clinical areas may require a specific risk assessment. These areas include (but are not limited to) operating theatres, critical care areas, mental health, laboratory settings, dental services, paediatric services and settings where communitybased services are provided. 3.4 Risk elimination and control strategies 3.4.1 Hierarchy of risk controls The OHS Regulation 2001 states that reasonably foreseeable risks must be eliminated. When elimination of the risk is not reasonably practicable, then measures to control the risk must be implemented. The OHS Regulation 2001 specifies the hierarchy (or order) of risk control measures that must be followed in regards to addressing identified hazards. Measures in relation to the elimination of sharps injuries are: 1. Elimination of sharp devices where reasonably practicable For example, pharmaceutical products that exist in a noninjectable form could be administered rather than medications by IM or SC injections. If elimination is not reasonably practicable then the risk must be minimised in the following specified order. A combination of the following measures is required to be taken to minimise the risk to the lowest level reasonably practicable if no single measure is sufficient for that purpose. 2. Substitution of the hazard giving rise to the risk For example, the replacement of a sharp drawing up needle with a blunt drawing up needle. 3. Isolation of the hazard from the person at risk For example, the immediate placement of a sharp in a rigid sharps disposal container situated at the point of use. 4. Minimising the risk by engineering controls For example, replacement of conventional intravenous devices with a needle-less system. 5. Minimising the risk by administrative controls For example, the development of a local sharps injury prevention policy that incorporates safe work practices. 6. Use of personal protective equipment (PPE) For example, using double gloves during surgical procedures. 3.4.2 Post exposure management HCWs who incur a sharps injury require expedient, timely, considerate and knowledgeable post exposure management. The basis of such management must be in accordance with PD2005_311 (HIV, Hepatitis B and Hepatitis C - Management of Health Care Workers Potentially Exposed), the key elements of which are: rapid assessment of an exposed HCW to ensure the timely administration of post exposure prophylaxis (PEP) when 18

appropriate; availability of assessment and management over a 24 hour period; and the process for reporting and post exposure management being made known to new staff during orientation and induction programs. Information on post exposure management procedures for sharps injuries should be provided in a range of formats. For example: attached to the identification badge of all workers; on safety information flip charts; in procedure manuals; by utilising the organisation s Intranet facilities: and any other notification system used by organisations to notify staff of emergency numbers and safety management strategies. Exposure management packs should be developed and made ready for distribution to healthcare workers and source patients in the event of a sharps injury. (SEE TOOL I) Staff nominated to manage exposed HCWs should receive specific training in BBV disease processes and counselling. 19

4.0 Documentation Relating to Sharps Injury Prevention Programs 4.1 Performance indicators When developing a sharps injury prevention program, consideration should be given to how the effectiveness of the program will be determined and continuous improvement ensured. Therefore, the identification and documentation of performance indicators (PIs) and the establishment of baseline data are integral components of the process. Specific targets relating to PIs should be set by each organisation. PIs for a sharps injury prevention program may include: the number of reported sharps injuries in the short-term (these may increase due to raised awareness among HCWs); the number of reported sharps injuries in the medium-long term (these may reduce due to risk control strategies and improved practices); the number of workers compensation claims relating to sharps injuries (a reduction desired); costs and lost work time associated with post exposure management and treatment (a reduction desired); the percentage of managers and/or staff who have attended sharps injury prevention training; the number of risk elimination and control strategies developed, implemented and reviewed within an organisation; and a change in the type or nature of sharps injuries reported. 4.2 Operational aspects Prevention of sharps injuries must be addressed in the operational policies of organisations such as infection control and OHS manuals. Organisations may also choose to develop separate sharps injury prevention guidelines. Documentation should also be maintained by organisations regarding the development of their sharps injury prevention program. Ideally, such documentation will include all steps of the risk management process, review of clinical practices, the outcomes of device trials and relevant PIs. 4.2 Evaluation and review Following implementation, all aspects of sharps injury prevention programs (including local documentation) must be evaluated. It is suggested that reviews should occur at least annually. Employers and managers must consult with staff to determine whether risk controls and other preventive actions are effectively eliminating or minimising the incidence of sharps injuries. Any aspects identified in need of update or improvement should be addressed and relevant adjustments made to local policies and procedures. Policy, procedures and devices must be reviewed if an incident occurs or if hazard reports indicate a potential risk. The OHS Regulation 2001 mandates the review of risk assessments and control measures when: 20

there is evidence that the risk assessment is no longer valid; injury or illness results from exposure to a related hazard; or a significant change is proposed to the place of work, work practices or procedures to which the risk assessment relates. Documentation that includes the names and designations of staff members who attend sharps injury prevention education and the dates of attendance should be maintained. Consideration should be given to incorporating documentation of the compliance with safe work practices relevant to sharps injury prevention into the performance evaluation for all staff. 21

5.0 Guidelines for a Sharps Injury Prevention Program 5.1 Key elements A sharps injury prevention program should, at a minimum, complement existing risk management programs within each organisation. Given the variability of demographics, case mix, HCW skill mix and service complexity of organisations, sharps injury prevention programs will, by necessity, vary. The international literature clearly specifies that the best outcomes for reducing sharps injuries are achieved when a combination of interventions is used. (SEE TOOLS J & K) KEY ELEMENTS of a SHARPS INJURY PREVENTION PROGRAM C O N S U L T A T I O N HAZARD IDENTIFICATION RISK ASSESSMENT RISK ELIMINATION and CONTROL STRATEGIES CLINICAL INDICATOR DATA RELATING TO SHARPS INJURIES CLINICAL PRACTICE REVIEW & REDESIGN DEVICE PROCUREMENT WORKPLACE SAFETY CULTURE INITIATIVE ORGANISATIONAL COMMUNICATION STRATEGY DOCUMENTATION PERFORMANCE INDICATORS EDUCATION & TRAINING POST EXPOSURE MANAGEMENT OPERATIONAL ASPECTS EVALUATION, MONITORING and REVIEW 22

6.0 Tools for Use in Developing a Sharps Injury Prevention Program The following tools are provided to assist and guide the establishment of a sharps injury prevention program. The use of the tools by organisations is optional. Tool A. Survey of healthcare workers on exposure to sharps injuries This survey will assist in assessing the reporting rates of sharps injuries by healthcare workers. It will also assist to review the efficiency of an organisation s post exposure management system. The survey has two sections: Part A assesses healthcare workers knowledge of procedures for reporting sharps injuries and the frequency of under-reporting; and Part B allows workers to comment on their experiences with the protocols after reporting an exposure. Information from this survey can be used to identify problems with either reporting of sharps injuries or the care received after an exposure. It may also help to identify areas for improvement through education, procedure revision, and/or system changes. An organisation may administer this survey as part of a baseline assessment and periodically thereafter (e.g. bi-annually). The survey could target either all staff or only those exposed to the risk for sharps injuries. Organisations that choose to administer this survey should adapt it to meet their needs. For example, the period of time for recalling exposures can be changed from 12 months to 3 or 6 months. Likewise, organisations may wish to exclude Part B and focus only on reporting processes. The survey is intended to protect the anonymity of respondents. If the number of healthcare workers in one or more of the occupational groups included is small (e.g. vascular access team) then these groups should be removed as an independent group and combined with another occupational group (e.g. nursing staff, laboratory staff). It is important that the confidentiality of the survey be emphasised in order to ensure the collection of accurate information and encourage staff participation. Computer analysis may prove more efficient and aid relevant statistics to be collated. POLICY SECTION LINK FOR THIS TOOL: 2.5.1 - Clinical indicator data relating to sharps injuries 23

Survey of healthcare workers on exposure to sharps injuries (sample) If you have questions relating to the completion of this survey, please ask for assistance. Question 1. Which of the following best describes your occupation / work area? (Tick only ONE response) Nursing staff [ ] Transport service [ ] Medical officer [ ] Central Supply staff [ ] Maintenance staff [ ] Phlebotomy team [ ] Vascular access [ ] Cleaning staff [ ] Laboratory staff [ ] Other staff [ ] (identify): Question 2. Which shift do you usually work? Rotating shifts [ ] Permanent day shift [ ] Permanent afternoon shift [ ] Permanent night shift [ ] Part A. Reporting of sharps injuries Question 3. Does our organisation have a procedure or protocol for reporting sharps injuries? Question 4. If yes to question 3, do you know how to report these injuries? Question 5. Who would you contact first if you were injured by a needle or sharp object? Question 6. In the past 12 months, have you sustained a sharps injury from a needle or other sharp object / instrument? Question 7. If yes to question 6, how many sharps injuries did you sustain during this time period? Question 8. Had any of the object(s) which led to the sharps injury (question 7) previously been used on a patient? Don t know [ ] Go to question 5. No [ ] Go to question 5. Yes [ ] No [ ] Yes [ ] Supervisor [ ] Don t know [ ] Staff health service [ ] Infection control [ ] Emergency Department [ ] General Practitioner [ ] Would not contact anyone [ ] No [ ] complete no more questions Yes [ ] 1 only [ ] 2-5 [ ] > 5 [ ] No - none [ ] Not sure [ ] Yes - all [ ] Yes - some [ ] 24

Question 9. How many of these injuries did you report? Question 10. If you answered none in question 9, for what reasons did you not report the injury? None [ ] All [ ] Go to question 11. Some [ ] Go to question 11. (Tick all relevant responses) I considered the risk too low to report [ ] I was unsure about who to report to [ ] I was advised not to report [ ] Too much time required to complete process [ ] Reporting process too complicated [ ] I was concerned about my confidentiality [ ] Fear of acquiring hepatitis B, C or HIV [ ] Concern over being judged incompetent [ ] Fear of being disciplined [ ] I accept injuries as an occupational hazard [ ] I had been vaccinated for hepatitis B [ ] Other [ ] Question 11. Did you seek treatment for the injury? No [ ] complete no more questions Yes [ ] Question 12. Where did you go to receive treatment after the injury? Part B. Experience with post exposure management (Tick only ONE response) Did not receive care [ ] Staff health service [ ] Infection control [ ] Emergency Department [ ] General Practitioner [ ] Outpatient clinic [ ] Other (please explain) Directions Please circle the numbers in the table below that most closely reflect your agreement or disagreement with each of the statements Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree A. I was seen in a timely manner 1 2 3 4 5 B. I was given sufficient information to make a decision about post exposure treatment 1 2 3 4 5 C. My questions were answered to my satisfaction 1 2 3 4 5 25

D. I was given sufficient information to understand the follow-up testing regime E. Post exposure procedures were followed appropriately by relevant staff during my follow-up treatment F. My post exposure treatment was managed in a manner consistent with the information provided during relevant training G. I was encouraged to call or come back if I had any concerns H. Staff made me feel that it was important to report my exposure Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 I. I did not feel rushed during my visit 1 2 3 4 5 J. The place where I received treatment was convenient for me K. Appropriate post exposure services were offered e.g. counselling 1 2 3 4 5 1 2 3 4 5 Please add any additional comments below. Thank you for completing this survey * Tool adapted from the Sharps Injury Prevention Workbook Centers for Disease Control and Prevention. Atlanta: Georgia http://www.cdc.gov/sharpssafety/pdf/workbookcomplete.pdf 26

Tool B. List of safety - engineered device categories CATEGORY DESCRIPTION 1. Injection devices Used for intramuscular and subcutaneous injections and includes single use syringes (syringe and needle), needles with needle guards for attachment to syringes, needle-less jet injection systems, and prefilled syringes: (A) Hypodermic needles and syringes (sliding sheath/sleeve; needle guards) (B) Retracting needles/syringes (C) Pre-filled Syringes (D) Insulin Injection Needles (E) Other 2. IV medication delivery systems 3. IV insertion equipment (IV catheters, etc.) 4. Blood collection equipment * Devices in this category currently on state contract can be found on NSW State contract number: 689 Used for the administration of medication or fluids through an IV catheter port or IV connector site. Many systems are offered with multiple components for medication vial and IV access for complete needle-less IV delivery (A) Needle-less IV access-blunted cannulae (B) Needle-less valve/access ports and connectors (C) Recessed/protected needle IV access (D) Pre-filled medication cartridge with safety needles (E) Needle guards for pre-filled medication cartridges (F) Other * Devices in this category currently on state contract can be found on NSW State contract number: 218 Used for accessing the bloodstream for the purpose of administering intravenous (IV) fluids. (Note: refer to blood collection section for winged steel needles that are also used for IV administration.) (A) Shielded or retracting peripheral IV catheters (B) Shielded midline IV catheters (C) Other * Devices in this category currently on state contract can be found on NSW State contract number: 218 (A) Arterial blood gas syringes (B) Safety-engineered blood collection needles (C) Safety-engineered blood collection needle with tube holders (D) Blood tube holders: safety-engineered and single-use (E) Winged steel needle (butterfly) blood collection sets (F) Closed venous sampling system (G) Blood donor phlebotomy devices (H) Plastic fingerstick sampling (capillary) blood collection tubes (I) Plastic blood collection tubes (J) Plastic blood collection tubes with screw caps (K) Umbilical cord sampling (L) Other * Devices in this category currently on state contract can be found on NSW State contract number: 646 27